Provider Demographics
NPI:1992776058
Name:BECERRA, MARY JOSEPHINE (LD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JOSEPHINE
Last Name:BECERRA
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JO
Other - Last Name:VINCENT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LD
Mailing Address - Street 1:744 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-9020
Mailing Address - Country:US
Mailing Address - Phone:918-599-5744
Mailing Address - Fax:918-599-1763
Practice Address - Street 1:744 W 9TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9020
Practice Address - Country:US
Practice Address - Phone:918-599-5744
Practice Address - Fax:918-599-1763
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1355133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200054920AMedicaid
OK200054920AMedicaid